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Jerald E. Wisdom, Jennifer Sun, Abumere Akinwale, Ahmed Soliman, Hillary A. Keenan, Lloyd P. Aiello, George L. King; Protection from Proliferative Diabetic Retinopathy in Patients with 50 or More Years of Type 1 Diabetes. Invest. Ophthalmol. Vis. Sci. 2012;53(14):5278.
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© ARVO (1962-2015); The Authors (2016-present)
To characterize factors associated with protection from development of proliferative diabetic retinopathy (PDR) among patients with ≥50 years of type 1 diabetes (Medalists).
Retrospective medical record review performed for Medalists with ≥2 visits to the Beetham Eye Institute of the Joslin Diabetes Center. Dates of DR progression were recorded on standardized forms and correlated with current hemoglobin A1c (A1c), body mass index (BMI), blood pressure (BP) and lipid parameters. ETDRS-protocol fundus photographs were reviewed for clinical level of DR severity.
For 158 Medalists (316 eyes), mean + SD follow-up duration was 16 + 13 yrs with 27 + 33 total visits. Average age at diagnosis was 10 + 6 yrs, diabetes duration 58 + 6 yrs, current A1c 7.2 + 0.9% and 47.5% were male. PDR was absent in 99 (63%) subjects and 207 (66%) eyes at earliest exam. Progression to PDR occurred in 35 (35%) subjects without PDR at baseline and 164 (52%) eyes overall. Current A1c, age and diabetes duration were not associated with PDR as an outcome. In contrast, current higher A1c, shorter diabetes duration, and older age were related to faster progression to PDR (P= 0.03, <0.0001, 0.0002, respectively). Among 75 subjects without baseline PDR who did not progress to PDR in either eye, 56% had A1c≥7% and 13% had A1c≥8%. Among 35 subjects without baseline PDR who did progress to PDR in either eye, 71% had A1c≥7% and 40% had A1c≥8%. Eyes without baseline PDR that did not progress to PDR (N=152) had a slower rate of 1-step DR worsening as compared with eyes that progressed to PDR (N=61, p<0.001). In eyes that did not progress to PDR, 99% of eyes that worsened had NPDR worsening prior to 20 years DM duration. By 20 yrs, 34/35 of the PDR progressing group already had PDR. No association was found between time to PDR and current BMI, BP or lipid parameters.
In subjects who survive 50 years or more of DM, progression to PDR is not correlated with the usual parameters of current A1c, BMI, BP or lipids, although A1c is associated with earlier PDR onset. The majority of Medalists who do not develop PDR are not well controlled by current standards (A1c≥7%). However, there is essentially no NPDR progression after 20 years of diabetes in this group - a time when nearly all progression to PDR has already occurred in the other Medalists. At least among subjects who survive with ≥50 years of diabetes, these data suggest factors that may protect against adverse effects of long term hyperglycemia, and that following 20 years of diabetes there is limited further DR progression.
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